Review Methods

Search Strategy: A systematic search was

conducted across a wide-ranging set of data-

bases: Ovid Medline, including In-Process &

Other Non-Indexed Citations, Ovid Embase,

Ebsco CINAHL and Cochrane Library.

The preliminary search strategy was devel-

oped on Ovid Medline using both text words

and Medical subject headings from January

2006 to February 2017 restricted to English

language humans. The search strategy was

modified to capture indexing systems of the

other databases. (Search strategies available

upon request).

To identify additional papers, the following

website was searched: palliative care

knowledge network

Furthermore electronic tables of content for the last two years were scanned for British Journal of Anaesthesia, Journal of Pain and Symptom Management, Pain and Palliative medicine. Reference lists of systematic reviews were

checked for any relevant studies. The search-

es generated 288 citations after removing

duplicates and irrelevant records. Figure 1

represents the flow of information through

the different phases of the review.

Inclusion: Studies reporting Palliative care or

cancer patients on opioid analgesics who

have been referred and had interventional

procedures as an adjunct to pain manage-

ment. Studies published in English from 2006

to current.

Exclusion: Studies set in a non-Organization

for Economic Cooperation and Development

(OECD) countries; Case series studies con-

sisting of less than 25 patients; non-english

language studies

Study selection/Quality Assessment/Data

Extraction: Study selection was based upon

review of the abstract by two independent

reviewers. The full text was then assessed

independently using a pre-designed eligibility

form according to inclusion criteria.

Any discrepancies between the two review-

ers were resolved by consensus or by re-

course to a third reviewer.

Context

In the majority of cancer patients, pain can be well controlled with conventional

analgesics, in accordance with the WHO three step analgesic ladder. However, in

some patients conventional analgesic strategies fail to provide effective pain relief.

In these patients, interventional pain techniques, such as neural blockade, may be

indicated. Patients who need advanced interventional pain management will

almost certainly already be taking high doses of opioids. Despite reductions in

opioid analgesia pre and post interventional procedure, there remain issues

regarding opioid toxicity following the intervention. This raises implications for

patient safety and wellbeing and highlights a need for local guidance/protocol to

reduce such risks by following the best evidence base to support patient

management.

Key Findings

The number of papers identified via our search strategy and review methodology is

shown on page 2. This process resulted in fourteen abstracts being identified as

meeting the inclusion / exclusion criteria. Upon review of the full texts, none of

these papers met the objective of this rapid review and all were excluded. Whilst

some of the papers examined interventional pain management in the population of

interest, no reference was made to the outcomes of interest, i.e. opioid toxicity and

its management. Other reasons for exclusion included non-OECD countries (3),

examination of only four cases (1) and no reference to interventional pain

management (2). Four of the fourteen papers were systematic reviews; as no

relevant papers were identified via our original search, relevant references from the

systematic reviews were also checked but no papers were identified as meeting the

objective of this rapid review.

There is a lack of evidence to support patient management pre/post interventional

procedure to minimise the risk of opioid toxicity. This highlights a need for primary

research to investigate this issue and, in the first place, to establish what proportion

of palliative care patients on opioid analgesics are referred and go on to have

interventional procedures, and what proportion of these go on to experience

problems with opioid toxicity post intervention.

A. Reliability of evidence

Not applicable

B. Consistency of evidence

Not applicable

C. Relevance of evidence

Not applicable

What processes decrease the risk of opioid toxicity following interventional procedures for

uncontrolled pain in palliative care or cancer patients?

Evidence Implications:

Clinical:

The lack of evidence to support

patient management pre/post

interventional procedure to mini-

mise the risk of opioid toxicity

highlights a need for primary

research to investigate this issue.

The proportion of palliative care

patients on opioid analgesics who

are referred and go on to have

interventional procedures should

first be established, along with the

proportion who go on to experience

problems with opioid toxicity post

intervention.

This lack of published data

highlights the potential importance

of registry studies. One example is

the National Registry for Invasive

Neuro-destructive Procedures in

Cancer Pain, which is designed to

track the role of cordotomy in the

management of mesothelioma-

related pain. Further registry studies

may be appropriate in order to

produce reliable data that could

help address the subject of this

review.

Policy:

There are no implications for policy

due to the lack of evidence.

Records identified through

database searching

(n = 355 )

Scre

enin

g In

clu

ded

El

igib

ility

Id

enti

fica

tio

n Additional records identified

through other sources

(n = 3 )

Records identified in total

(n = 358)

Records screened after

duplicates and

irrelevant records

removed

(n = 288)

Records

excluded

(n = 70)

Records screened for

eligibility

(n = 131)

Full-text

excluded, with

reasons

(n = 117)

Full-text articles

assessed for eligibility

(n = 14)

Studies included in the

rapid review

(n = 0)

Flow Diagram:

What processes decrease the risk of opioid toxicity following interventional procedures for

uncontrolled pain in palliative care or cancer patients?

Studies reviewed at full text for potential inclusion:

We searched a comprehensive set of databases and information sources for the best available evidence relating to de-

creasing the risk of opioid toxicity following interventional procedures for uncontrolled pain in palliative care or cancer

patients. However, we could not identify any eligible studies due to the complexity of the topic area, studies reviewed

at full text are cited below:

1. Amr YM, Amr YM. Comparative study between 2 protocols for management of severe pain in patients with unresectable pancre-

atic cancer: one-year follow-up. Clinical Journal of Pain. 2013;29:807-13.

2. Amr YM, Amr YM. Neurolytic sympathectomy in the management of cancer pain-time effect: a prospective, randomized multicen-

ter study. Journal of Pain & Symptom Management. 2014;48:944-56.

3. Arcidiacono PG, Arcidiacono PG. Celiac plexus block for pancreatic cancer pain in adults. [Review]. Cochrane Database of System-

atic Reviews 2011 11 Mar 16;(3):CD007519. doi: 10.1002/14651858.CD007519.pub2.

4. Gulati A, Shah R, Puttanniah V, Hung JC, Malhotra V. A retrospective review and treatment paradigm of interventional therapies for

patients suffering from intractable thoracic chest wall pain in the oncologic population. PAIN MED 2015 Apr;16(4):802-10.

5. Heneka N, Shaw T, Rowett D, Phillips JL. Quantifying the burden of opioid medication errors in adult oncology and palliative care

settings: A systematic review. Palliat Med 2016 Jun;30(6):520-32.

6. Hivelin M, Hivelin M, Wyniecki A, Plaud B, Marty J, Lantieri L. Ultrasound-guided bilateral transversus abdominis plane block for

postoperative analgesia after breast reconstruction by DIEP flap. Plastic & Reconstructive Surgery 2011 Jul;128(1):44-55.

7. Mitchell A, McGhie J, Owen M, McGinn G. Audit of intrathecal drug delivery for patients with difficult-to-control cancer pain shows

a sustained reduction in pain severity scores over a 6-month period. Palliat Med. 2015;29:554-63.

8. Nagels W, Nagels W, Pease N, Bekkering G, Cools F, Dobbels P. Celiac plexus neurolysis for abdominal cancer pain: a systematic

review. [Review]. Pain Medicine. 2013;14:1140-63.

9. Plancarte R, Plancarte R, Guajardo-Rosas J, Reyes-Chiquete D, Chejne-Gomez F, Plancarte A, et al. Management of chronic upper

abdominal pain in cancer: transdiscal blockade of the splanchnic nerves. Regional Anesthesia & Pain Medicine. 2010;35:500-6.

10. Raphael J. Cancer Pain: Part 2: Physical, Interventional and Complimentary Therapies; Management in the Community; Acute,

Treatment-Related and Complex Cancer Pain: A Perspective from the British Pain Society Endorsed by the UK Association of Palliative

Medicine and the Royal College of General Practitioners. Pain Medicine. 2010;11:872-96.

11. Tei Y, Tei Y, Morita T, Nakaho T, Takigawa C, Higuchi A, et al. Treatment efficacy of neural blockade in specialized palliative care

services in Japan: a multicenter audit survey. Journal of Pain & Symptom Management. 2008;36:461-7.

12. Vayne-Bossert P, Vayne-Bossert P, Afsharimani B, Good P, Gray P, Hardy J. Interventional options for the management of refracto-

ry cancer pain--what is the evidence?. [Review]. Supportive Care in Cancer. 2016;24:1429-38.

13. Wiechowska-Kozlowska A. Boer K, Wójcicki M, Milkiewicz P. The efficacy and safety of endoscopic ultrasound-guided celiac plexus

neurolysis for treatment of pain in patients with pancreatic cancer. Gastroenterology Research and Practice Volume 2012, Article ID

503098, 5 pages doi:10.1155/2012/503098

14 Wong FCS. Intercostal nerve blockade for cancer pain: Effectiveness and selection of patients. Hong Kong Medical Journal.

2007;13:266-70.

What processes decrease the risk of opioid toxicity following interventional procedures for

uncontrolled pain in palliative care or cancer patients?

For further information please contact PaCERSWCRC@cardiff.ac.uk

Additional materials available upon request:

List of studies reviewed at full-text with reasons

Critical appraisal / data extraction forms

Search strategies

List of excluded references from the systematic reviews

This report should be cited as follows: Palliative Care Evidence Review Service. A rapid review: What processes decrease the risk of opioid toxicity following interventional procedures for uncontrolled pain in palliative care or cancer patients? Cardiff: Palliative Care Evidence Review Service (PaCERS); 2017 May

Permission Requests: All inquiries regarding permission to reproduce any content of this review

should be directed to PaCERSWCRC@cardiff.ac.uk

Disclaimer: Palliative Care Evidence Review Service (PaCERS) is an information service for those in-

volved in planning and providing palliative care in Wales. Rapid reviews are based on a limited litera-

ture search and are not comprehensive, systematic reviews. This review is current as of the date of the

literature search specified in the Review Methods section. PaCERS makes no representation that the

literature search captured every publication that was or could be applicable to the subject matter of

the report. The aim is to provide an overview of the best available evidence on a specified topic using

our documented methodological framework within the agreed timeframe.

What processes decrease the risk of opioid toxicity following interventional procedures for

uncontrolled pain in palliative care or cancer patients?